Head and neck conditions

Question 1

one of the commonest neonatal facial anomalies. In ~80% of cases, the two features tend to occur together

Answer 1

Cleft lip and palate

Question 2

Associations of cleft lip and palate :

Answer 2

aneuploidic syndromic: tends to occur with types II, III and IV 5
- trisomy 13
- trisomy 18

non-aneuploidic syndromic
frontonasal dysplasia
Gorlin syndrome
Kallmann syndrome
Stickler syndrome
TAR syndrome
VACTERL association
fetal valproate syndrome

non-aneuploidic non-syndromic
- Dandy-Walker continuum
- holoprosencephaly: often with type
IV
- pentalogy of Cantrell

Question 3

MOST common location of cleft lip and palate?

Answer 3

majority are unilateral and 70% of these are on the left.

Question 4

What uss feature can be seen with cleft lip and palate?

Answer 4

there can be polyhydramnios if the defect is severe and impairs swallowing

Question 5

What is the most common type of facial fractures, accounting for ~45% of facial fractures, and are often missed when significant facial swelling is present.

WHat is the second most common facial bone fracture?

Answer 5

Nasal bone fractures

Zygomaticomaxillary complex (ZMC) fractures

Question 6

midface fractures which collectively involve separation of all or a portion of the midface from the skull base. In order to be separated from the skull base, the pterygoid plates of the sphenoid bone need to be involved as these connect the midface to the sphenoid bone dorsally.

Answer 6

Le Fort fractures

Question 7

WHat are the three types of le fort fractures

Answer 7

• Le Fort I is a floating palate (horizontal) - fracture line passes through the alveolar ridge, lateral nose and inferior wall of the maxillary sinus
• Le Fort II is a floating maxilla (pyramidal) - fracture arch passes through the posterior alveolar ridge, lateral walls of maxillary sinuses, inferior orbital rim and nasal bones
• Le Fort III is a floating face (transverse) - transverse fracture line passes through nasofrontal suture, maxillo-frontal suture, orbital wall, and zygomatic arch/zygomaticofrontal suture

Question 8

Zygomaticomaxillary complex (ZMC) fractures, also known as tripod, tetrapod, quadripod, malar or trimalar fractures, are seen in the setting of traumatic injury to the face. They comprise fractures of the:

Answer 8

zygomatic arch

inferior orbital rim, and anterior and posterior maxillary sinus walls

lateral orbital rim

Question 9

Sinonasal inflammatory conditions include?

Answer 9

acute sinusitis
- Pott puffy tumour
chronic sinusitis
fungal sinusitis
– non-invasive: hyphae do not invade mucosa
- allergic fungal sinusitis
- sinus fungal mycetoma
– invasive: hyphae seen invading mucosa +/- beyond
- acute invasive fungal sinusitis
- chronic invasive fungal sinusitis
- granulomatous invasive fungal
sinusitis
granulomatosis with polyangiitis (formerly known as Wegener granulomatosis)
sinonasal polyposis

Question 10

an acute inflammation of the paranasal sinus mucosa that lasts less than four weeks and can occur in any of the paranasal sinuses.

WHat are the common findings on CT?

Answer 10

Acute sinusitis

peripheral or central mucosal thickening
gas-fluid levels in the paranasal sinuses
gas bubbles within the fluid / / bubbly secretions
obstruction of the ostiomeatal complexes.

Question 11

What are the complications of acute sinusitis ?

Answer 11

erosion through bone
subperiosteal abscess
frontal sinus superficially (Pott puffy tumour)
frontal or ethmoidal sinuses into the orbit (subperiosteal abscess of the orbit)
dural venous sinus thrombosis
intracranial extension
meningitis
subdural empyema
cerebral abscess

Question 12

refers to a non-neoplastic complication of acute sinusitis. It is characterised by a primarily subgaleal collection, subperiosteal abscess, and osteomyelitis. It is usually related to the frontal sinus but is sometimes secondary to mastoid pathology.

Rarer aetiologies include trauma, intranasal cocaine, and methamphetamine abuse, and craniotomy.

Answer 12

Pott puffy tumour

Question 13

MOST common infectiuve agents of pott puffy tumour?

Answer 13

Streptococcus spp.
Haemophilus influenzae
Staphylococcus spp.
Klebsiella sp.

Question 14

Chronic sinusitis is defined clinically as a sinonasal infection lasting more than 12 weeks. Causes include:

MOST common anatomical variant found in chronic sinusitis?

Answer 14

paranasal sinus anatomical variants obstructing drainage (see below)
sinonasal polyposis
chronic allergy

chronic infection:
chronic bacterial sinusitis
chronic allergic fungal sinusitis
cystic fibrosis

odontogenic

oncha bullosa (30%)
posterior nasal septal deviations (25%)
uncinate process variations (25%)
paradoxical middle turbinate (10%)
agger nasi cells (10%)
Haller cells (9%)

Question 15

What are the two groups of fungal sinusitis?

Answer 15

two groups, depending on the presence of fungal hyphae within or beyond the mucosa:
INVASIVE
allergic fungal sinusitis
sinus fungal mycetoma

NON-INVASIVE
acute invasive fungal sinusitis
chronic invasive fungal sinusitis
granulomatous invasive fungal sinusitis

Question 16

most common form of fungal sinusitis and is common in warm and humid climates.

Associated with ? (65% of cases)

Answer 16

allergic fungal sinusitis

Asthma

Question 17

MOST common location (sinuses) for allergic fungal sinusitis?

Answer 17

The ethmoid sinus is the most common location, followed by the maxillary, frontal, and sphenoid sinuses.

Question 18

indolent and non-invasive fungal colonisation of the paranasal sinuses.

Answer 18

Paranasal sinuses mycetomas, or fungus balls

Question 19

What is the most aggressive form of fungal sinusitis. It is seen particularly in immunocompromised patients and is the source of significant morbidity and mortality

Answer 19

Acute invasive fungal sinusitis

Question 20

Acute invasive fungal sinusitis imaging features?

What are the possible complications

Answer 20

acute infection generally does not demonstrate hyperdense material within the sinus on non-contrast CT

Aggressive surgical debridement is usually required.

Complications include:
intraorbital extension
intracranial extension
leptomeningeal enhancement
intracranial granulomas
epidural abscess and empyema
vascular invasion
cavernous or dural venous sinus thrombosis
mycotic aneurysm formation
cerebral infarction or haemorrhage
systemic dissemination

Question 21

How do you distinguish chronic invasive fungal sinusitis from acute?

Answer 21

CHRONIC has longer clinical history (usually more than 12 weeks) 5

hyperdense material within the sinus is more common

sclerotic changes to the bony walls of the affected sinuses representing chronicity of the disease

Question 22

represents maxillary sinus atelectasis that results in painless enophthalmos, hypoglobus and facial asymmetry

Answer 22

Silent sinus syndrome

Question 23

What are the CT features of silent sinus syndrome?

Answer 23

The sinus is fully formed but fully opacified and reduced in volume with inward bowing of all four walls.

Question 24

form of neural tube defect and a type of cephalocele where brain tissue and overlying meninges herniate out through a defect in the cranium.

Frontoethmoidal encephaloceles are more common in the south and south-east Asian populations.

Answer 24

encephalocele

Question 25

Occipital encephaloceles may be associated with a number of additional abnormalities:

Answer 25

Chiari malformations

Dandy-Walker malformations

Meckel-Gruber syndrome

Question 26

Frontoethmoidal encephaloceles manifest as a clinically visible mass where?

Basal encephaloceles are internal and are not generally externally visible, although they may manifest as a lump or bump in the oropharynx or nasopharynx.

Answer 26

along with the nose
The intracranial root of most frontoethmoidal encephaloceles lies at the foramen caecum, a small ostium located at the bottom of a small depression anterior to the crista galli and formed by the closure of the frontal and ethmoid bones

Question 27

Rare cause of airway obstruction.
refers to narrowing of the pyriform aperture and results from early fusion and hypertrophy of the medial nasal processes.

MOST common associations?

Answer 27

Pyriform aperture stenosis

alobar and semilobar forms of holoprosencephaly
facial haemangiomas
clinodactyly
pituitary dysfunction
central megaincisor (in 75% of cases)

Question 28

refers to a lack of formation of the choanae, the openings providing communication between the nasal cavity and nasopharynx. It can be unilateral or bilateral.

Associations?

Answer 28

Choanal atresia

Syndromic associations include
CHARGE syndrome
Crouzon syndrome
DiGeorge syndrome
amniotic band syndrome
fetal alcohol syndrome
Treacher Collins syndrome
Other associations include
intestinal malrotation
craniosynostosis
congenital heart disease

Question 29

commonest causes of nasal obstruction in neonates

Answer 29

Choanal atresia

Question 30

common incidental benign midline nasopharyngeal mucosal cysts

Answer 30

Tornwldt cyst

Question 31

Imaging features of Thornwaldt cyst?

Answer 31

Typically they are well circumscribed rounded lesions immediately deep to the mucosa. They are usually nestled between and anterior to the longus colli muscles they elevate the mucosa forming a convex surface into the nasopharynx. They are variable in size, ranging from a few millimetres to a few centimetres in diameter, but are typically 2-10 mm in size

Question 32

refers to the presence of multiple benign polyps in the nasal cavity and paranasal sinuses.

Answer 32

Sinonasal polyposis

Question 33

Conditions known to be associated with nasal polyps?

Answer 33

Conditions known to be associated with polyps include:

infectious rhinosinusitis

cystic fibrosis

allergic fungal sinusitis

asthma

nickel exposure

eosinophilic granulomatosis with polyangiitis

Question 34

solitary sinonasal polyps that arise within the maxillary sinus (antrum). They pass through and enlarge the sinus ostium and posterior nasal cavity at the level of the choana.

Answer 34

Antrochoanal polyp

Question 35

complete opacification of one or more paranasal sinuses by mucus, often associated with bony expansion due to obstruction of the nasal sinus drainage.

Answer 35

Paranasal sinus mucocele

Mucoceles distort local anatomy and exert pressure on adjacent structures as they enlarge. Examples include:

frontal mucocele extending into the front of the orbit, presenting as a mass

posterior ethmoidal mucocele compressing the orbital apex

sphenoidal mucocele extending posteriorly to impinge on the pituitary gland and brainstem

maxillary mucocele may elevate the orbital floor with resultant proptosis

Question 36

MOST common location for paranasal sinus mucocele?

Answer 36

The frontal sinus is particularly prone to developing mucoceles, and up to two-thirds of all mucoceles occur there. The ethmoidal sinuses are the next most common (~25%), whereas the maxillary and sphenoid sinuses are infrequently involved

Question 37

Imaging features of paranasal sinus mucocele?

Answer 37

Areas of complete bone resorption may be present, resulting in bony defect and extension of the ‘mass’ into adjacent tissues 2,3. Peripheral calcification is sometimes seen 2. Following administration of contrast, only peripheral enhancement (if any) is seen.

Question 38

MOST common location of paranasal sinus osteoma and associations

Answer 38

frontal (80%) > ehtmoidal (15%)
Gardners syndrome

Question 39

type of Schneiderian papilloma, representing an uncommon non-cancerous sinonasal tumour that mostly affects middle-aged men. They occasionally undergo malignant transformation. On imaging, they classically demonstrate a convoluted cerebriform pattern seen on both T2 and contrast-enhanced T1 weighted MRI images.

Answer 39

Inverted papillomas
Males > female
40-60 yrs

Question 40

MOST common location for Inverted papillomas

Answer 40

Inverted papillomas most commonly occur on the lateral wall of the nasal cavity, most frequently related to the middle turbinate/middle meatus and maxillary ostium, although they are seen elsewhere in the nasal passage. As the mass enlarges it results in bony remodelling and resorption and often extends into the maxillary antrum

Question 41

Classic imaging feature of inverted papilloma

Answer 41

demonstrates a distinctive appearance, referred to as convoluted cerebriform pattern, seen on both T2 and contrast-enhanced T1 weighted images. This represents alternating lines of high and low signal intensity, the appearance of which has been likened to, albeit loosely, cerebral cortical gyrations. This sign is seen in 50-100% of cases and is uncommon in other sinonasal tumours.

Question 42

rare benign, but locally aggressive, vascular tumours that occur almost exclusively in young men; usually between the ages of 10 and 18.

Answer 42

Juvenile nasopharyngeal angiofibromas

occur almost exclusively in males and usually in adolescence (~15 years)
The most common of the benign nasopharyngeal neoplasms.

Question 43

Where do Juvenile nasopharyngeal angiofibromas commonly arise ?

Answer 43

these masses are thought to arise from the region of the sphenopalatine foramen, they are usually sizeable at diagnosis, frequently with extension medially into the nasopharynx, laterally into the pterygopalatine fossa and, over time, beyond into the orbit, paranasal sinuses, intracranial cavity and infratemporal fossa.

Question 44

Majority of Juvenile nasopharyngeal angiofibromas are supplied by which artery?

Answer 44

external carotid artery

internal carotid artery: less common, usually in larger tumours

Question 45

rare sub type of sinonasal carcinoma. It is considered a highly aggressive neoplasm arising in the paranasal sinuses.

Where do they arise ?

Answer 45

Sinonasal undifferentiated carcinoma (SNUC)

Most arise within the ethmoid sinuses and superior nasal cavity.

Question 46

tumours arising from the basal layer of the olfactory epithelium in the superior recess of the nasal cavity.

How do they present?

Answer 46

Olfactory neuroblastomas, also known as esthesioneuroblastomas
(bimodal age distribution )

usually present as a soft tissue mass in the superior olfactory recess involving the anterior and middle ethmoid air-cells on one side and extending through the cribriform plate into the anterior cranial fossa. Contrast enhancement is often marked in both CT and MRI studies.

Question 47

Prognosis is significantly affected by the presence of distant metastases (see olfactory neuroblastoma staging).

Answer 47

no distant metastases: 60% 5-year survival 6

distant metastases: 0% 5-year survival

Question 48

What is Acrania anencephaly sequence

Answer 48

progression from a relatively normal-appearing exposed brain due to an absent cranium (acrania) to an amorphous brain mass (exencephaly) to no recognisable brain tissue (anencephaly)

Question 49

? a chronic granulomatous infection involving the upper respiratory tract due to Klebsiella rhinoscleromatis. It initially involves the nasal mucosa but it may progress to involve any part of the upper respiratory tract

Answer 49

Rhinoscleroma

between 10 to 30 years old. It is endemic in Central America, Egypt, tropical Africa, India, and Indonesia 3.

Question 50

Characteristic radiological feature of rhinoscleroma

Answer 50

bilateral or unilateral expansile nasal masses, lesions are usually homogeneous, hyperdense and non-enhancing

masses usually extend through the nasal nares anteriorly and into the adjacent paranasal sinuses

lesions line the sinus wall causing bone sclerosis, bone thinning (pressure atrophy) or it may absorb it with extrasinus extension

no bone destruction which helps to differentiate it from malignant lesions

in long standing cases, rhinoscleroma may extend to involve other parts of the upper respiratory tract:

such as pharynx with nodular infiltration of the oropharynx, tonsillar bed, soft and hard palate

may also show laryngotracheal involvement, the usual site of laryngeal involvement is the glottic–subglottic region showing concentric narrowing of the airway, thickening of the tracheal wall and nodular thickening of the tracheal mucosa